Lecture: Phaco Fundamentals I

This is a lecture geared toward the eye surgeon who is transitioning to phacoemulsification cataract surgery. The ideal participant will be the intraocular surgeon who already has experience with manual small-incision cataract surgery and / or extracapsular cataract extraction.

Topics to be covered include:

Overview of resources available to prepare for phaco

Mastering the continuous curvilinear capsulorhexis

Techniques of nuclear disassembly including ‘divide and conquer’ and ‘phaco chop’

Lecturer: Dr. Lisa Park

Transcript

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DR LISA PARK: So, again, you’ve joined the Cybersight webinar, and I’ll be talking about phaco fundamentals. This is part I of II, and I just wanted to get started by letting you know that I have no financial disclosures, I’m not a paid consultant, I have no financial disclosures, so everything that I say is my own opinion, and I hope it will be useful for you. So I have — I practice currently in Manhattan, New York. And I was, for 11 years, a clinical associate professor and the associate residency program director at the New York University School of Medicine. So I just wanted to ask everybody who you are. And take a poll of who we have with us today, and some of our audience members, to get some idea of who we have with us. Okay. So which of the following best describes your current position? Are you an ophthalmology attending or resident, are you an optometrist, a technician, an ophthalmic nurse, or another eyecare provider? And if you could answer for me, that would be great. Although I see nothing here. Here we go. And… Okay. So let’s go ahead — and I believe that you can click and answer and participate in this poll, so we can get an idea of who has joined us today. I’m hoping to be able to tailor some of my comments and some of the discussion or the chats to the audience that is here today. Okay. So I see that there are a number of you who are answering. Okay. And we have here… It looks like… Okay. So about 77% of you are ophthalmology attending or resident, we have a few optometrists with us, and we have 7 who are other eyecare providers today. And I just want to say that we welcome everybody. We hope that this conversation is going to be useful to all who provide care, although I will be focusing, obviously, on surgical technique. Okay. The second question… I’m gonna have to go back here. The second question that I would like to ask is: For those of you who are in practice, how long have you been in practice? Are you currently in training? In practice 0 to 5 years? 5 to 10 years? 10 to 20 years? Or greater than 20 years? And let’s see if I can go to question number 2. And here we go. So, again, how long have you been in practice? And we have a lot of you voting currently. And we’re just gonna wait a moment to see… Fantastic. Just to let you know, I’ve been in practice for almost 12 years now. And I completed my training at NYU, where I was a faculty member for many years. So about 15 years. Okay. Fantastic. This is great. We have a very nice mix. So… It looks like almost a third, a third, a third. Currently training, recently out of training, 0 to 5 years, in training, 5 to 10 years, and then — almost evenly spread. 10 to 20 years. So fantastic. So hopefully some of the things that I’m gonna talk about are gonna be useful at all stages. Okay. And we’re gonna go now to… Question number 3. And that is: Are you currently doing surgery? So are you currently — for those who are performing cataract surgery, do you currently perform extracap or manual small incision cataract surgery? I know that in various parts of the world, that many eyecare providers don’t have access to the materials needed to perform surgery, and there are many eyecare providers who are performing surgery who are not physicians, so we understand that there is a wide range here. Okay. And what we see here… Okay. And that is… So about 2/3 of people who are on this webinar today are performing some type of large incision or manual small incision cataract surgery. There are a number who are not. So hopefully this will be really interesting for everybody. Okay. And then we’re gonna go on to… Question 4. And that is… Have you received — for those of you who are performing any type of cataract surgery, how many of you received any kind of phaco training? So we know that there are many parts of the world that are offering training courses, and I will speak about one of them that I participate with, but I’m just curious to know how many of you have already received phaco training? So it looks like… That a fair number of you have already received training. And my hope is that this will be an additional means of getting some information. Okay. So again, a third have not received training and two thirds have. So great. This will be right up everyone’s alley, I think. Okay. And then we’re gonna try one last question. And that is… Okay. For those who have already received training, do you perform phaco regularly? So we know that oftentimes many people get trained, but they don’t have access to the materials or the supplies in order to continue performing surgery regularly, and that’s a challenge, and so that’s something that we want to also discuss. And so… We’re letting everybody weigh in right now. And this is fantastic. I think this is really going to be so helpful, because we’ll have a nice discussion, hopefully, that’s relevant to many of you. And that is… Okay. So for those of you who have received training, half of you are still performing it regularly, and half of you are not. And that is something that we see, because of the challenges of — especially the consumable supplies. And we’re gonna talk a little bit about that, hopefully, if we get a chance. Okay. All right. So let’s move on. Okay. Here we go. So I’ll just tell you a little bit more about myself. As I mentioned, I’m at New York University. I was in the Department of Ophthalmology for many years. This was my office. This is my operating room. I operate with, really, very good equipment, which we’ll talk about. But, you know, I’ve been teaching for the last 11, 12 years. I’ve taught 70 residents over that time. This is my last current class of residents. They operate in their very last year. So after 4 years of medical school, they’re in training for 3 years, and it’s in their very last year that they perform intraocular surgery. I run the surgical curriculum, and run a wet lab course once a year for residents throughout New York City. And this is where they get a lot of their hands-on experience. I’m currently on staff at the Manhattan Eye, Ear, and Throat hospital. This is where phacoemulsification was first invented in the late 1960s, by Charlie Kelman, and I was very fortunate to have met him, and have heard him lecture many times, talking about the innovation of phaco, his journey to implement it, and it’s really an amazing story, and it’s been wonderful to be part of this historical institution, where this first started. I’m also a volunteer surgeon, and I travel to the developing world on a regular basis. I volunteer with an organization from California called Hospital De La Familia, and have been traveling to Guatemala for the last 10 years. I’m also on the board of the organization Vision Care, which is based in Seoul, Korea, and we have recently opened a New York branch. And I travel regularly to Ethiopia, where we’ve developed a partnership with a hospital in the city of Addis Ababa, and this is the room that we have equipped in the clinic. This is our operating room there. And, as I mentioned, we have developed a phaco training course, in which we partner with the Ophthalmic Society of Ethiopia, training two doctors a year, that go through a 6-month-long program, and I go at the end of the session, in order to perform surgery together with the doctors that are there. And the reason why I share this with you is to let you know that I understand the challenge — some of the challenges. It’s obviously different in different places, but some of the challenges of doing cataract surgery or phacoemulsification under conditions where you don’t have all of the materials that you need. But I will absolutely say that the general principles are the same anywhere. And that very successful surgery can be done in the developing world, and this is a question, actually, that was sent to me ahead of time, and it says that some people argue phacoemulsification is not for low income countries. Do you think this is right? And the answer is I believe phacoemulsification can be performed in any part of the world. Obviously it requires certain technology and it requires certain equipment, but the technology and the equipment has now been developed to the point where it can be modified for anywhere in the developing world. And, again, the general principles that are in place, I think, can make this successful anywhere, and should be brought anywhere. Does that mean that there’s no place for manual small-incision? No. There’s always a place for that surgery. And so I think it’s very important for surgeons to have both techniques under their — in their armamentarium. And my goal is to try to educate for phaco. So what we’re gonna talk about today are three general topics. The first we’re gonna talk about is preparation. How do you start getting information and preparing for phaco? And we’ll talk about the capsulorrhexis, which is often one of the most difficult parts of — or one of the more important skills to learn in the beginning. And then we’re gonna talk about general techniques of nuclear disassembly. And that is divide and conquer and phaco chop. So if we prepare for phaco, of course it’s always important to read up and to look at a lot of videos, and secondly, it’s important to understand what the equipment is and to know it in detail, what’s possible, what’s not possible, how you can maximize and make things more efficient for you, and then clearly to do practice before operating intraocularly, and I’ll talk about some wet lab models, artificial systems that are available, and simulations that can be very helpful. Some of the educational resources that I recommend are here. And these are three really excellent, excellent texts. The first is by Michael Colvard. Achieving Excellence in Cataract Surgery. It’s a step by step approach, and I do think this is a standard text which has been used that is excellent. The second, in the middle, is Bonnie An Henderson’s book, Essentials of Cataract Surgery. This is actually a compilation of the course that she initiated over a decade ago, that is taught at the Harvard Mass Eye and Ear Infirmary. I’ve been fortunate to be a participant in this course for the last 10 years. This is actually given to about 150 rising seniors, and it is fantastic, because the level of lectures are really amazing. And the third is a little bit more of an advanced text. And that is David Chang’s text, Phaco Chop. If you’re able to get your hands on it, it also contains a DVD, which is also very helpful. He provides this in many locations for free, especially to surgeons in the developing world. So keep your eyes open at various meetings, because he is happy to provide this as part of his work at ASCRS. I also recommend this book. And this is the American Academy of Ophthalmology’s BCSC book. Book 11, if you’re familiar with this series. Lens and Cataract. So I was very honored to be on this committee, and actually rewrote the cataract surgery chapter, so this is new this year. The entire series gets revised every 3 years, and this year we also have included videos that are available directly from the text via QR code, so I encourage any of you who have old versions of this to seek out the new version. I do think that it has been very revised. So what are other sources that you might look at? You know, videos are always the best. And so I think the most popular has been YouTube. But you have to be careful what you look at there. Because people post anything up there. And so things that might not be reasonable are there. Eyetube is another venue that you can look for eye-specific videos. But what I would encourage you to look at is actually the American Society of Cataract and Refractive Surgery website. There is a very brand-new Center for Learning, and if you can see here at the bottom right, there’s an arrow pointing to a button called Phaco Fundamentals. And I am very pleased to sit on the committee of Phaco Fundamentals, and we actually look at and vet a lot of material that’s out on the internet, and they’re available by educators around the country, who submit, and we posted them, and these are available for free. You can create a free login to access these videos. I know that sometimes video is difficult to see, depending upon your internet access, but it is a very good resource, when you have the opportunity to log on there. And this is the website. And again, full courses, including the Harvard Mass Eye and Ear course, and the Northwestern course, are available in their entirety, at this website. So the second thing I’ll tell you is that it’s really important to become familiar with your equipment. So the most important piece of equipment, I’m gonna say, in any type of surgery, is actually gonna be the microscope. And I have a very nice microscope. I’ve used both the Leica and the Zeiss microscopes. But I understand that you have to use what you have. But you have to maximize what it is that you’re using. And one of the things that I would really encourage is to play with some of the settings to make sure that you are maximizing them. Oftentimes one of the things that I find is that surgeons don’t look at the correct magnification to see what they need. Either they’re too close, they’re too far away — so you basically want to get very comfortable. And when you look at videos, you’ll see the magnification that is ideal. The second is that you want to keep the eye centered. So oftentimes, if you don’t have a foot pedal, it’s difficult, because if the patient gets out of your field of view, then it creates a problem in the middle of your surgery. And so what I generally do is I actually — even in my own OR, I tape the patient’s head to the bed, in order to really center them and not let them move around. And the last is: Be aware, if you do have a foot pedal — I was recently operating in Ethiopia, and we were moving the microscope by hand, until the last day, and then I realized there was a pedal underneath, and we actually had foot controls. And so it’s important to get used to that, so you can easily maneuver during surgery. The second is to get to know your phaco machine. I use the Centurion. It is a very nice machine. However, I would say that the vast majority of surgeons don’t know the machine intimately, and it’s important to do so, to maximize your ability to do your surgery. The surgery that I do on my missions is usually a tabletop machine, and I’m just gonna discuss it very briefly, to talk about the things that you can adjust, rather than just pushing phaco 1 or phaco 2 or ultrasound 1 or ultrasound 2, to understand that you can adjust those settings, in order to make your technique improved. So there’s phaco power, there’s vacuum, and then there’s irrigation. And we’ll talk about them briefly. Phaco power — you want to use only an amount of energy that you need. And so generally if you have a fixed phaco, I would say 30%, 40% phaco is a reasonable place to start. If you have a harder lens, 50% to 60%. If you have linear, I actually use a linear setting, all the way up to 80%, but if you’re using 80%, just straight fixed power, that is too high. And so you’ll have to adjust accordingly. And you’ll have to adjust based on what’s happening. So if the lens is being pushed away from you, you may need to increase your power, or if you are getting wound burn or wound gape at the end of your cases, then you’re gonna need to decrease the power. Vacuum. The difference between ultrasound 1 and ultrasound 2 is the amount of vacuum. And so essentially the two settings that you want to know are: During sculpting, you should have low vacuum. And so I have generally 30% or 40% vacuum. 30 or 40 millimeters of vacuum. And then during quadrant removal, you’ll raise the vacuum. And that’s gonna depend very, very much on your machine. On the Centurion, I’m going up to 400, but I’m gonna say that that’s very, very high. So you will have to see how well you’re grasping the pieces and adjust your vacuum accordingly. And then irrigation. So that’s the amount of fluid that’s going in the eye. You’ll control that by adjusting the bottle height. So if your anterior chamber is collapsing, you’ll raise the bottle, or if iris is coming out through the wounds, or you’re getting too much fluid, then you’ll have to lower that, usually manually. The latest machines now have active fluidics, in which there’s actually no bottle. There’s actually a compression on an irrigation bag. And so that can be adjusted also, in the machine settings. The handpiece is an important thing to get to know. And one of the most important things for the beginning phaco surgeon is to get comfortable holding it. And to figure out where your hand is going to be holding it like a pencil. I’ve noticed sometimes beginning surgeons will hold it very awkwardly, because they believe that in order to fit through the wound, they’re gonna have to position it in a way that is not natural, and so it’s important to establish that very early. And to realize that the phaco tip has many different configurations. So it could be straight, it could be bent or angled, and then the tip can be beveled. The benefits of having more of a bevel are that the cutting ability of that tip will be improved. The disadvantages become that it’s harder to occlude and grasp pieces. So one has to come up with what is the best scenario for the individual surgeon. I recommend personally, in the beginning, to go with a straight tip and a small bevel, a 30-degree bevel, before going to more advanced techniques. Another important thing to understand and realize is that the sleeve is a very, very important part of the tip, and should not be ripped or broken, and it should allow the irrigation holes to be on the side, so you can avoid irrigating the endothelium. Another major point that must be emphasized is that the tip has to equal the size of the wound. So I’ve been in situations where whatever blade is handed to me and you make the incision, and then the tip goes in, and the tip does not equal the wound. If the wound is too big, you will not get intrachamber stability, and there will be leaking, and you will never be able to have a closed system. If you’re too tight and this wound is too small, then you’re gonna be pushing into the eye, and there will be possibly wound burn or wound gape, and so one has to widen the wound a little bit. And so this is something to be very aware of, that there are different-sized tips or different-sized blades and different-sized handpiece tips. The blades vary from 2.2 to about 3.2 millimeters. And so just be aware smaller is always better. You can always enlarge a smaller wound. You can’t make a larger wound smaller. If that happens, where you make a larger wound, I actually will close the wound, and I will go somewhere else and make a second wound. The phaco foot pedal is important to understand. That there are three positions. The first position is irrigation, the second position is aspiration, and third position is phaco. So you want to get a feel on your foot pedal. It’s a linear setting. It’s often difficult for the beginning surgeon who is just pressing down and not realizing it’s a linear feel. So you have to gradually feel for those three positions, in order to maximize your ability to phaco. And then lastly, be familiar with supplies. We’re gonna talk a little bit later about different kinds of choppers, different kinds of hooks, and different kinds of viscoelastics. If you have the opportunity to use this fantastic simulator, this is what our trainees use before they go to the operating room, and it enables them to practice all these things. Looking through the scope, using the foot pedals, and manipulating the eye ahead of time. But these are hard to come by. We perform a wet lab course ahead of time, so they can practice on animal eyes. We use pig or cow eyes. The anterior capsule is more rubbery than the human eye. My recommendation is freshly obtained eyes are the absolute best. But in Manhattan, we don’t have cows running around on the streets, so we generally get them from the butcher shop, we put them in the freezer, and then we heat them up before using them. However, there are many artificial systems, and this is a system that we use, and that is the KITARO by FCI Ophthalmics. You can see that it has a nice model of the artificial eye, and it actually has the ability to make wounds and to perform phaco on various types of nuclei. And there’s a new system I just checked out at our last Academy meeting. And this is by OKULO. A very nice system that is now available also. Okay. So that’s just some tips on how to begin preparing for phaco. And now we’re gonna go talk about capsulorrhexis. This is the part of surgery — I’m assuming that you’ve — we’ll talk next time about making wounds, but this is the part that usually, for a surgeon who already is performing manual small incision or extracapsular surgery, this is the part that is different. And why do we do a continuous curvilinear capsulorrhexis? And what we’re doing here is, opposed to making a can opener — just an opening in the anterior capsule — we need to make a very smooth curvilinear opening, in order to prevent radial tears, which can then propagate posteriorly. And what happens is, when we’re doing phaco, and we’re pushing on the lens, if there is a tear that wraps around, then we’re gonna end up with a dropped nucleus. And even if it doesn’t drop, we can end up with vitreous prolapse, if that tear radializes. We also are trying to make a capsulorrhexis that’s a particular size. So usually 1 millimeter smaller than the edge of the optic, in order to keep a lens centered and prevent it from prolapsing out of the bag. Another question that was posed to me was: Is femtosecond laser the future? This is now being used for capsulorrhexis as well as softening the lens, and I will say in New York, it has not widely been adopted. The vast majority of us are still doing manual curvilinear capsulorrhexis. And the reason why is it’s faster. It’s faster, it’s easier. To get into a place to use a femtosecond laser takes a lot of time. And so usually fast surgeons are able to do this much more efficiently and quickly, and for the vast majority of routine cases, femtosecond laser is not necessary. We are using it in order to package in with usually premium lenses, in order to guarantee centration, and to guarantee a particular size. But we can talk about that more later. But it has absolutely not become the norm. So the first thing I will say is we need to maximize visualization to do a capsulorrhexis. And that is good dilation. So using all manners of dilating the pupil is very important. And I know that with extracap or manual small incision, a poorly dilated pupil may not stop you, but I’m gonna say to perform the capsulorrhexis, you need to see well. And so these are the drops that I use. I use phenylephrine, tropicamide, cyclogyl, and flurbiprofen, a COX-2 inhibitor, to prevent the pupil from coming down during surgery. I use 3 sets of drops, 5 minutes apart, and very importantly, I put epinephrine in my irrigation bottle, at the concentration of 1:1,000,000. So if I have a bottle of 1:1,000, and I have a 500-CC irrigation bottle, I’m putting about 0.4 or 0.5 CCs of epi in the bottle. And this is something that I learned when I was in Ethiopia. That I couldn’t understand why, during surgery, the pupil kept on coming down, and I kept on asking if there was epi in the bottle, and they didn’t quite understand what I was asking them, and finally when I showed them, and I said — listen, this needs to be in the bottle every single time, it made a huge difference during surgery. Head positioning is important, again. Taping down the head. And I like to use a Trypan blue or ICG dye to stain the anterior capsule, when it’s available. And so this is a video that I’m gonna show of one of my residents, a first case. So this is a typical — injecting Trypan blue dye. You don’t need to use an air bubble, but you need to really coat and then rinse. And it really only takes about 20 seconds for the capsule to be stained very well. Viscoelastic is then injected. This is a biplanar clear corneal wound, which we’ll talk about next time. And then we begin with a capsulorrhexis needle. So a couple of comments that I’ll make — you’ll see here that the entire rhexis is going to be made with just the needle and not with forceps. And I will say that I tend to do it just with the needle. It’s a little bit slower. It’s not as fast. But it’s very convenient, because you don’t have to switch instruments. And I also think that often capsulorrhexis forceps, even in my own operating room, often get broken easily, and the ends do not necessarily meet, then, which becomes very inconvenient. And so I actually teach all of my residents to perform the entire rhexis with just the bent needle. The needle itself — I actually also bend myself, when I’m on a mission. So oftentimes I’ve been handed needles that have been bent by the ophthalmic nurses or technicians, and I will actually just bend my own. Simply because I like the end bent only. And it’s a very fine tip that is easier to do under the microscope than to do grossly. And you can see here that this is a very slow, deliberate pulling of the rhexis around. And that’s the other tip that I will give, is that going from a can opener to a curvilinear capsulorrhexis — it’s important to note that the motions are much smaller and should be smooth. Clockwise versus counterclockwise — it doesn’t matter. But I will say generally under the wound first is preferred, because of visualization. So it’s more difficult to perform the capsulorrhexis away, and then bring it under the wound at the end, because it’s generally harder to see. So I generally start either to the left or to the right, but bring it under the wound first, and then go all the way around. And again, the forceps versus cystotome doesn’t matter, but your choice might be influenced by the size of your wound. So in other words, the smaller a wound that you make, the more difficult it is to put a capsulorrhexis forceps in. And so, again, I tend to use the needle all the way around. I do think it’s easier. It’s slower, but it’s — one can do it very successfully with a 27-gauge needle that’s bent under the microscope. The key is to keep that flap flapped over, and to pull always tangentially. And so the thing that’s very important to do is to avoid pulling to the center. So when the flap starts to go out, it’s very easy to try to pull centrally, to bring it back in, and I’m gonna say that’s absolutely the opposite of what you want to do, because if you pull centrally, the rhexis is actually gonna go out further, and so you have to really flap over and pull in a tangent to the circle that you’re trying to make. I think we have a video here. And this is just a capsulorrhexis that’s under more difficult conditions. So this is a patient that’s asteroid hyalosis. So you can see here that the visualization is a little bit difficult, actually, because of depth perception and seeing all that hyalosis and those calcium crystals that are within the eye. Here staining is really important. Because it enables you to see the plane of where the rhexis is going to be. So, again, puncture, pulling over of the capsular flap, and oftentimes — just very carefully trying to bring that flap over. You can see again — so the flap has gone through the side and then under the wound first, and then we’re gonna bring it around. And you can see the most important thing is that this flap is completely flapped over and front. And so the motion that I usually tell people to use is to try to sort of grab and lift, grab and lift, and just push it along gently, in a gentle motion, in order to keep that intact. If you pick at it, then the tendency is for that capsule to rip and break. And so one tries to maintain the integrity of that anterior capsule by just gently pulling it and letting that flap actually draw the opening all the way around. Okay. And then let’s say the rhexis does start to go out. How can we bring it back? I talked about not pulling to the center. However, there is a technique that can be used that seems to counteract that. And this is called the little rescue technique. And you can see here in this case the rhexis has started to radialize and go out. And so what we’re doing is we’re actually flapping the flap back over. So flapping the flap back over with viscoelastic, and now using the forceps to just gently bring this towards center when it’s not flapped over, and rip just so it comes back a little bit. And one might say why don’t you just continue to do that all the way around? And the reason why is because that’s very difficult to control. And so you can only do it for small segments, and then one must then actually flap it back over in order to bring that back around. So you can see it’s flapped back over, but it’s coming around here. And now — flapped it completely around, and it’ll just meet all the way to its origin. But that’s the little rescue technique, and that’s the only time we pull to the center. When it’s radializing, we flap it back over, and then we bring it back to center. Okay. Sometimes the capsulorrhexis doesn’t work so well, so we convert to a can opener. So in this particular case, it’s a very intumescent lens. It’s been stained. You can see immediately that even with not much movement that this rhexis or this anterior capsule is starting to go out. Even with almost no movement. So there’s a lot of positive pressure. And so here I’ve decided to change over to a forceps to see if it can be brought around, and what I can see is it can’t. So already I’m pulling, and so I’ve decided to open this. With a can opener technique. And try to save as much as I can, so — is it possible to open it somewhere again and bring still a nice curvilinear motion here? The answer is no. And so I’m just gonna make some gentle openings here to try to save as much as I can. Again, the goal here is to prevent those radial tears. To actually not provide too much pressure, because I can tell this lens is about to pop out. And I just want to make an opening that’s good enough for this lens to come out easily. So lenses come out. And you can see it’s actually come out very nicely. There is a part of that rhexis that looks like it’s going out superiorly. But the bag is really intact. And you can see that the cortical clean-up — that everything is maintaining itself. So I made a decision to put a lens into the capsular bag, and what I’ll do here is actually rotate that lens to avoid radializing that tear, and you can see even in this particular case, we were able to save the bag and actually end up with a very, very nice result. So even converting to a can opener doesn’t mean that phaco can’t be performed. Okay. And again, here — this is to show you that — let’s say you make a rhexis, and it’s a little bit too small. So here we’re going along, and I’m gonna say this is probably a 4.5-millimeter rhexis. Sometimes it’s hard to judge based on the size of the pupil. I would say this is fairly well dilated, but not widely dilated. But our rhexis is a little bit small in this particular case. And so when this happens, then, you can make this larger on the far end. And you can see here — so I’m not gonna meet the original origin, but I’m actually gonna spiral it and go around a little bit more. This becomes difficult to visualize. See, again, under the wound. This is the most difficult part to visualize. And so I’m gonna just make it — I’m gonna bring it back together right here. But just by spiraling it a little bit, we can make the wound — or make the capsulorrhexis just a little bit bigger, in order to make sure that we’re able to get out this lens. And so this requires careful visualization in completion of that opening. And then lastly I’m just gonna show you — this is a nice tool, if you have it, and this is what I use to teach our residents to make an exact size. So this is a 5-millimeter — basically a caliper. That can be introduced into the eye under a dispersive viscoelastic, and what’s nice about this is we use this to practice pulling up against the side of that plastic instrument, and you can see here now — this is practicing with a Utrata forceps. And it enables us to then use this as a guide to prevent this from going outwardly, and also too you can make this completely centered, and a nice 5-millimeter perfect rhexis here. I call this the poor man’s femtosecond laser, because you can really do a perfect circle, utilizing this particular instrument. So that is the capsulorrhexis. And so now we’re gonna go on to… Let’s talk about… Nuclear disassembly. And this is just the basics. I’m gonna go into more detail about — people have been asking about settings and things like that. So this is just the basics. So what is divide and conquer? The first thing we need to do is we’re obviously gonna groove into the nucleus. And the most important thing here is sculpting a good central groove. And this is harder than it might seem. You want to press down on ultrasound while you’re grooving forward. And then let go of that ultrasound when you’re moving the phaco tip back. And that’s to minimize the amount of energy that’s being used. We want this groove to be about 1.5 phaco tips wide. In order to essentially get good movement of your instrument inside the eye. And then respect the shape of the lens. So, in other words, I always talk about it like scooping ice cream or deeper in the center than on the side. So it’s not a straight groove all the way across. It’s deeper in the center of the groove. We obviously want to avoid puncturing straight through into the posterior capsule. How deep do you go? You basically want to go until you’re deeper than the midpoint, until there’s a change in the red reflex. That’s the best way to determine how deep you’ve gone. And then rotate this nucleus. So we’re gonna push against the walls of the groove. And we know that the force is a function of radius. So, in other words, if you push your instrument out further into the periphery, you’re going to be able to rotate this around much more easily. And then we sculpt the cross groove. So we’ll groove once. We’ll turn the lens. And then we groove across. And so we want to avoid the rhexis, obviously. Again, respect the contour of the lens, and we can continue to rotate this all the way around, until the grooves are complete. And so this is an example of making — sculpting and grooving. So you can see that phaco is only on as we’re pushing forward. It’s not on when we’re pulling back. We’re making this deeper in the center. And it doesn’t have to be long. The most important thing is that it’s deep and it’s a little bit wider than the size of one phaco tip. So 1.5 times the width. We’ve turned. We’re now grooving across. And, again, deeper in the center is more important. A little bit wider, in order to put our instruments in. And then using, again, the second instrument to turn this lens all the way around. Sometimes we’ll go back and extend the initial groove that was made, in order to really make this effective. And you can see the change in red reflex that’s at the bottom of this lens. And then turning all the way around to complete this complete cross. And this is a traditional divide and conquer. So, again, here’s the cross that we’ve made. And then we’re gonna crack this lens apart. So the goal here is to just make pieces that are small enough to bring up and out. There are two techniques for cracking the nucleus. One is what we call the traditional means. And that is putting a phaco tip and then a second instrument on either side and creating what we call an A to V motion. So A to V, so we’re putting our instruments here and then bringing them apart. The second is to do what we call cross cracking. And that is an X motion. We’re putting a phaco tip here and a second instrument here, in order to push them apart. So sometimes we get a little bit more leverage, instead of this way, traditional motion. We can cross them and push this way. So we like to propagate in the periphery first. And then to start to propagate and back-crack that. And this is very important. That it’s a horizontal crack. And we want to propagate it all along. Make this two heminuclei. And again, this is one of the things that my beginning residents often misjudge, and that is — they don’t crack all the way across. They see the opening in the center and they think that’s enough. And I tell them — listen, you want to really free the two halves of the nucleus, if possible. And so this would be a crack. So this is the traditional motion to split this lens in half. And you can see cracking distally first. And then centrally second. Okay. And this is another video. And this is in the basic science book. So this is grooving. So you can see my settings here. That I have relatively low vacuum. Less than 100. It’s about 80. My setting here — you can see that it’s variable, that I’m only pressing, and that until I see here — that the red reflex has changed, I put two instruments in at the bottom, and now just break them apart. And you can see really verifying that the crack is complete, two heminuclei have really come apart. And now we’ll move on to — once you’ve cracked, how do you remove the quadrants? We’re gonna change the high vacuum, and then impale the quadrant, using ultrasound, burying the tip all the way, and then building vacuum, to pull the piece to the central safe zone. And this is the part which I also feel with beginning phaco surgeons is difficult, and that is the concept of burrowing in on position 3 on the foot pedal and coming to position 2 without moving your hands, in order to grab that piece. We’re talking about trying to remove pieces of a pie, essentially. And so the most important part here is not the hand motion, but actually the foot pedal motion. And that is, again, going from 3 to 2, in order to grab that piece, and then to safely bring that to safety in the center. When you get to the last piece, you have to use a second instrument to protect your capsule, because you can get postocclusion surge, and basically vacuum up your posterior capsule into the phaco tip, if you’re not protecting yourself at the very end. And so here is an example. So this is high vacuum. That piece coming forward. And the most important thing I’m going to emphasize here that you can see is — there’s very little movement of the handpiece itself. So sometimes we do see a little bit of jostling about and reaching for and grabbing and going forward to the piece. I’m gonna say the most important thing here to remember is: It’s foot pedal control. Using the vacuum and the machine to allow these pieces to come forward and to try not to chase the pieces, because that is where, then, you can run into trouble. And then manipulating — so that you have pieces always in front of us. So the pieces in front, vacuum to grab, and then a second instrument to perform some maneuvers, to chop the lens, but again, we try to maintain this phaco tip in the center — so not more than 50% into the center of the eye, because that’s where you can run into trouble. So, again, we’re using vacuum to allow these pieces to come forward and come towards the handpiece. The second instrument is a little bit far away. So you can see here the second instrument is now in front of the phaco tip to prevent that posterior capsular bag from coming up and hitting the phaco and creating a posterior capsular rupture. And again, we’re letting — this is all foot pedal control. So we’ll let the vacuum bring those pieces forward. And then to allow those pieces to then be emulsified. So it’s a combination of position 3 and position 2, to allow those pieces to come forward. And again, not chasing, but again, using the foot pedal to allow those to come into the eye — I mean come into the handpiece. So that’s divide and conquer. Okay. All right. We don’t have much time, so I’m gonna talk very quickly — and we’ll go into more detail about phaco chop next time. What are the advantages of chopping? Rather than sculpting, this uses less energy, and it puts less stress on the zonules. You’re not pushing the lens. Because mechanical chopping is done with a second instrument, phaco is performed centrally, away from the posterior capsule. There are two types of chop, and that’s horizontal chop and vertical chop. That means that there are different kinds of choppers, and it’s very important to know what kind of chopper that you have, because they’re not gonna be the same. These are horizontal choppers that have a cutting edge on the inner aspect, on the inner rim here. And the motion is to engage the lens and then to bring the chopper from the periphery to the center, and then to push the two pieces apart in a horizontal manner. So basically you want to grab the lens proximal to the center, phaco to the center, and then usually if you can bring the chopper around the equator, that’s gonna be your most effective horizontal chop. Okay. So let’s take a look here. Okay. So you can see here — this lens has been cracked. We’re going to engage, bring the chopper around the equator, and then basically bring it in a smooth motion towards the phaco tip. We have now decompressed the eye. We have a piece that’s out. And from my standpoint, we’re home free. The lens — the pieces are gonna come out easily. So again, high vacuum, bring the chopper around the back, and just bring it basically towards the phaco tip, and allow those pieces to chop off. And in this particular case, this is a traditional stop and chop maneuver, and so the lens has been grooved and cracked, and now we’re just chopping, horizontally chopping the second half. We’re gonna, again, place the piece in front of us, engage, bring the chopper around, and then essentially, in one swift motion, bring it towards the phaco tip, and then you can see here again we’re on — vacuum of max is gonna be around 280. And we’re gonna try not to chase this piece. We’re gonna let the vacuum do the work for us and bring that second piece towards us. Vertical chop is a different maneuver. And that requires a very sharp end on a chopper, here and here. And this is gonna be used to impale, in a vertical motion, and then bring the pieces apart. This makes the best use of the planes of the lens. And you can see in this case the chopper is being brought down in a vertical motion right in front of the phaco tip, and then pushed in a horizontal and vertical fashion. So the pearls here is: You have to engage the piece very well. Otherwise you’re gonna push the piece off. And then put the chopper right next to the phaco tip, if you can. And here’s vertical chop. And so we’re going to — there’s no groove. We’re gonna just engage the lens. Put the chopper right in front. And basically push apart. And you can see here — here my vacuum is quite high, in order to be able to achieve that. So, again, here is a complete case of stop and chop. So we’re gonna make a quick groove here. We’re gonna groove. It’s a 1.5 phaco tips wide. We’re gonna wait until we see that red reflex change. And so we’re gonna go ahead and crack this nucleus apart. We’ll make a nice crack. Propagate it all the way. There are two heminuclei. And we’re making sure that they’re really apart. Gonna turn the lens, I believe. Engage with higher vacuum. I think I’m going for a different instrument. And that’s a little bit of a vertical chop there. And so just trying to get this piece up and out. So, again, my goal here is not to reach out into the periphery with my phaco tip, but instead use the vacuum ’til these pieces come forward. You can see my vacuum is here. The highest vacuum is gonna be around 400. But I’m using it rarely. So it’s a linear vacuum. I’m gonna turn the lens so it’s in front. Engage again. And use a horizontal chop. So some of the choppers can be used for both. My favorite chopper is this instrument, called a Seibel chopper. It has a little bit of a rounded edge. But it has a very good — and a little bit of a paddle that can turn the lens — but it also can do a nice horizontal chop very easily. And so, again, you can notice that we’re using the vacuum to let those pieces come towards the phaco tip, and we’re gonna protect by putting the second instrument right in front. Okay. So in summary, then, we’ll use the right instrument to do chop. For horizontal and vertical chopping. And we’re going to grab the lens with good vacuum. And then be flexible. Use the most convenient technique, obviously, at the moment. Okay. So this ends the formal part of our program. And I just want to see if there are any questions that you have. And so you can chat with me to ask questions. Okay. So I have a question here from Dival Patel, who’s asking: What energy settings do you use for chopping soft nuclei? And the answer is soft nuclei are hard to chop. And it depends upon how soft. So with a very soft lens, if there is, for example, a posterior polar cataract, or a PSC cataract, and that’s the reason that the vision is compromised, then I actually will do a pop and chop. So I’ll actually use pretty aggressive hydrodissection to bring that lens up and then out of the bag, and then actually just use vacuum in order to phacoemulsify that lens. Chopping a soft nucleus is very difficult, and so depending upon, again, how soft it is, I would say that a better approach is to try to go for prolapsing that lens, if possible. Okay. All right. A couple of other questions here. All right. Okay. Dr. S Propacar Krishna Charya asks: Is it a posterior Y-suture visibility that guides the stop sculpting or red reflex visibility? So I’m gonna say if you can see those sutures, then that’s fantastic. However, usually that’s usually not the guide that I’m using. It’s the red reflex. So once you’ve sculpted through enough, and you see a change in the red reflex, that is usually what we use to guide our conclusion of sculpting. Okay. A few other questions that I have here include… Okay. I’m going to answer… How do you manage… The question disappeared. The question was about pseudoexfoliation. So what do you do in a pseudoexfoliation? Pseudoexfoliation is probably one of the greatest challenges and one of the things that we see the most in the developing world that causes fear, and so there are two things that are problematic. Number one, poor dilation in a pseudoexfoliation patient. And so in that particular case, then everything that you can do to maximize dilation is helpful. All the things that I talked about, including using the appropriate medications and drops, putting epinephrine in the bottle, and then if you have the need to, perhaps capsular tension rings or iris hooks, or in worst case scenarios, we do sphincterotomies, where we just cut the iris in order to get visualization. That’s the further thing. And number two, the second thing, is obviously the zonules. And making sure that the zonules are intact. And minimizing the risk to the zonules. So I would say in that particular type of case, technique is everything. So I’ve seen cases where there’s been too much manipulation during the surgery, and that’s actually ripped all the remaining few zonules out in a pseudoex patient, and so that is what I would advise, is that in those particular cases, the main goal is to try to avoid manipulating the lens significantly, and to try to get that lens up and out as quickly as possible. Okay. We actually have a number of questions here. Okay. How much time can Trypan blue dye be safely kept in the AC without damaging the endothelium? That’s a good question. I would say that… I mean, we generally don’t leave the Trypan blue dye in longer than a minute. I’ve left it a minute. 60 seconds. And actually, in early cases, with my residents, I’ll tell them — put it in for 30 seconds. We sit there and we watch the clock, 30 seconds, to make sure that it really gives a good stain. I don’t know if there’s a maximum amount of time, but generally we wash it out after a minute or so, and it’s usually not problematic. I did have a case that was presented to me of someone who injected — accidentally injected Trypan blue actually into the corneal stroma, and didn’t actually get inside the eye, and in that case, the cornea was stained. However, it actually disappeared within 24 hours, and so that is something that — if that happens, then you just hold off on surgery, and come back another day. Okay. Let’s take a look. Somebody else also asked here — what is your opinion of doing phaco with the lens in the AC? And I’m gonna say in many cases, I actually do that. Is it safer? It’s safer obviously for the posterior capsule, and so if it’s safer for the posterior capsule, however, the disadvantage is you’re gonna damage the corneal endothelium with your phaco energy, and so in those particular cases, A, I wouldn’t do it with a very, very dense lens, where you’re gonna use a lot of energy, and B, I would continuously add viscoelastic, in order to protect the endothelium. And so you have to add viscoelastic continuously, and try to stay at the iris plane, if at all possible. With a very soft lens, where it’s gonna be mostly aspiration, not a lot of phaco energy, then I’m gonna say that is a very, very viable thing to do. Pop the lens into the AC and perform the phaco there. Again, try to stay at the iris plane if at all possible. Okay. And then I have a question here. Is it better to do a slightly leaky wound, rather than a tight wound, to prevent wound burn? So we talked about wound size. And the answer is… If you think you’re gonna get wound burn, then yes, a little bit of a wider wound is better. What I’ve found is, with some of these tabletop phaco machines that we’re getting wound burn — in almost every single case, even without a lot of phaco — what I’ve actually done is — it’s better to go with a scleral tunnel. A scleral tunnel wound. So push the wound back from the clear cornea a little bit. We’ll take down the conj. Don’t go that far, but actually just go — just even half a millimeter into the sclera makes a huge world of difference. And actually, that’s how I traditionally do all of my cases, when I’m on a mission, is actually to do a scleral tunnel. Okay. So we have actually a number of other questions, but our time is up. And so what I’ll be doing is I’ll try to answer some of these questions by text, but also we’ll keep track of all these questions, and in our phaco fundamentals II, I’ll open with some answers. At the next session, we’ll be talking more about phaco settings, phacodynamics, machine settings, we’ll talk about viscoelastics, we’ll talk about choppers, and different instruments. So I hope this has been very helpful. It’s been fun. And I look forward to joining you again sometime soon. Okay. Take care.